Patient Name: Todays Date: *General Patient Information Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status Email Phone: Home ( ) - Cell ( ) - Mailing- Address, City, State & Zip *PARENT OR RESPONSIBLE PARTY (if different from patient) Name of Insured Relationship to Patient Date of Birth / / SS# - - Sex: M F Marital Status Email Phone: Home ( ) - Cell ( ) - Billing - Address, City, State & Zip *INSURANCE INFORMATION (Please present insurance card at time of check in). Primary Insurance Name Policy Holder s Name SS# - - Date of Birth / / Group # Contract # Employer Name: Employer Phone #: - - Relationship of patient to the Insured **Do you have secondary Insurance? *In case of Emergency, who should be notified (other than those already listed above)? Name: Phone: - - Relationship: *All of the above is correct to the best of my knowledge, and I agree to notify this office in a timely manner of any changes. Date / /20 Patient or Responsible Party Signature
PATIENT NAME_TODAYS DATE What is the main reason for your visit today? *Past Medical History: (please check all that apply) *must check None if none apply Anxiety Arthritis Asthma Atrial fibrillation Depression Diabetes Stroke Thyroid Problems -Hyperthyroidism -Hypothyroidism GERD (Acid reflux) Bone Marrow Transplantation Hearing Loss Leukemia Organ Transplant BPH (Prostate Enlargement) Lung Cancer Breast Cancer High Blood Pressure Lymphoma Colon Cancer Prostate Cancer High Cholesterol Seizures Radiation Treatment End Stage Renal Disease Coronary Artery Disease COPD HIV/AIDS Hepatitis Shingles Shingles vaccine? OTHER: NONE *Past Surgeries: (in the last year) NO PRIOR SURGERIES *Skin Disease History: (please check all that apply) *must check None if none apply* Acne Actinic Keratosis Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Other: NONE Do you wear Sunscreen? Yes / No If yes, what SPF? *Medications: (Please list all current medications including over the Counter) NO MEDICATIONS *Allergies: (Please list all allergies) NO ALLERGIES
PATIENT NAME_TODAYS DATE *ALERTS: (please check all that apply) Allergy to adhesive Do you take Blood thinners or aspirin Allergy to lidocaine or other anesthetics Defibrillator or Pacemaker History of MRSA Allergy to latex Artificial heart valve Rapid heartbeat with epinephrine Artificial Joint Replacement Allergy to topical antibiotics NO ALERTS APPLY Primary Care Physician: Office# / / Referring Physician: Office# / / Pharmacy Name: Pharmacy# / / Pharmacy City: *Pharmacy Zip Code: (required) Preferred phone to contact you? Home work mobile Is it okay to leave a detailed message? yes no Occupation: *Smoking Status: (tobacco, cigarette) Never smoke Former Smoker Current smoker Current someday smoker *Alcohol Use: None Less than one drink per day 3 or more drinks per day *Family History (please check all that apply) Melanoma Skin Cancer (nonmelanoma) Psoriasis Thyroid Disease Autoimmune Disease **Only first-degree relatives** Depression Diabetes Hair Loss (Alopecia) Lupus
PATIENT NAME_TODAYS DATE *Review of Symptoms: Are you currently experiencing any of the following? (Please check all that apply) Nausea/vomiting Hay fever Fever or chills Dry skin Hair loss Unintentional weight loss Thyroid problems Night sweats Abdominal pain Sore throat Headaches New lumps or bumps Blurry vision Problems with healing Joint aches Rash Muscle weakness Depression Fatigue Neck stiffness Suicidal thoughts Easy bruising Photosensitivity Problems with bleeding Shortness of breath Dry eyes Problems with scarring Dry lips Immunosuppression Anxiety NO SYMPTOMS Other symptoms: *FEMALES ONLY (Please check all that apply) PREGNANT PLANNING PREGNANCY in next 6-12 months NURSING Hysterectomy Tubal ligation Ablation Birth Control Pills IUD NO Yes / Comments Name of B/C How long have you been taking this B/C Other contraception Abstinence
HIPAA PATIENT CONSENT FORM Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice The Practice reserves the right to change the Notice of Privacy Practices The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions The patient may revoke this Consent in writing at any time and all future disclosures will then cease The Practice may condition receipt of treatment upon the execution of this Consent. This Consent was signed by: Date: Printed Name Patient or Representative Date: _ Signature Relationship to Patient (if other than patient) Witness: Date: Printed Name Practice Representative
Here at Ginsburg Dermatology Center, our goal is to provide quality medical care in a timely manner. We have adopted the following policies to help us serve you better. No Shows and Cancellations. If you fail to show for your appointment or do no cancel your appointment 24 hours in advance, We charge a fee of $50.00; and all Fees will need to be paid before your next appointment. Please note that excessive no-shows or cancellations may result in termination of being your provider. Copayments - Copayments are due at the time of service. We are contracted with your insurance company and do not waive copayments. Deductibles Deductibles owed are due at the time of service. We are contracted with your insurance company and do not waive deductibles. Referrals some insurance policies require you to have a referral from your primary care physician, if you fail to get your referral before your office visit there is a chance that your insurance will not pay for that claim, the payment liability will be your responsibility to cover. Self-Paying patients- We at Ginsburg Dermatology Center are happy to see all patients. However, we are bound by our contracts with the insurance companies to file a claim if you are insured. By checking this box and signing below, you are certifying that you are uncovered by any and all insurance companies. Cosmetic Patients- All fees are due at the time of service. Medical Records We will be happy to provide you with your medical records. You must first sign a medical release form. Fees may apply. Search Fee $5.00 Pages 1-25 $1.00 per page Pages 26+ Postage Storage search $.50 per page At cost At Cost By signing below, I understand the policies at Ginsburg Dermatology Center. Signature Date